Using the well baby checkup to screen for autism

In 2007, the American Academy of Pediatrics published guidelines recommending that all children be screened for autism at their 18 and 24 month well baby checkups. While these recommendations have not been universally implemented in clinical practice, these guidelines are a positive step forward. New research from the Baby Siblings Research Consortium suggests that signs of autism can be detected as early as 6-12 months. Early detection and subsequent early intervention provide hope of changing the developmental trajectories of children with ASD to improve their outcome.

A recent study published in the Journal of Pediatrics, and supported by Autism Speaks, aims to address each of these challenges by utilizing a checklist called the Communication and Symbolic Behavior Scales Developmental Profile Infant-Toddler Checklist. Lead author Karen Pierce, Ph.D. of UCSD asked pediatricians to use this instrument as part of a well-baby checkup. This checklist was developed by Amy Wetherby, Ph.D., who was instrumental in creating the Autism Video Glossary. The instrument is also available online at www.firstsigns.org.

The researchers took a multi-phase approach. They first provided training to pediatricians on the signs and symptoms of autism. Such an approach has been used successfully before by a group at Vanderbilt University. However, this study screened infants as early as 12 months of age and conducted the 1 year screening in pediatricians’ offices, which had not been done before. Next, parents were asked to fill out the questionnaire in the waiting room, and the questionnaire was scored by the time the parent met with the physician. The checklist responses from parents then were reviewed by participating pediatricians, and children who were flagged by the questionnaire were referred to a UCSD clinic for further evaluation. About 12% of children who were screened were referred to the clinic for an evaluation. Of those, about half were followed to 3 years of age and 17% were later diagnosed with an ASD. Other diagnoses included learning disabilities and developmental disabilities.

This study is important for several obvious and some not so obvious reasons. First, and perhaps most importantly, this study shows that it is feasible for pediatricians to become actively engaged in an easy-to-implement early screening program for ASD for children as young as 12 months of age. Also important, all families who were interested were able to obtain the services of a clinician very early in their child’s development. For those that were later diagnosed with an ASD, 100% received treatment by 17 months.

Second, a training program that increased awareness about ASD in the medical community among pediatricians produced a long-term impact on their practice. Only 22% of pediatricians involved were screening for autism at 1 year before the program; now all of them report they are maintaining the use of the toddler checklist.

However, this method is not without its limitations. The effectiveness of this program depends on the ability of pediatricians to have access to and a relationship with a clinic they can refer to, which is not the case in every area of the country or the world. Also, not all infants who were referred went on to receive an evaluation, for reasons that are unclear. The results suggest that early screening may enhance, not replace, evaluation at 18 and 24 months to ensure that cases that may not be detected as early as 12 months are not missed.

We applaud the work of Pierce and her colleagues for their efforts to identify autism as early as possible and bring primary medical care staff into that process. Studies such as this highlight the many very important steps, undertaken by the Baby Siblings Research Consortium, the Autism Treatment Network and the Toddler Treatment Network, to ensure that children are screened as early as possible, seen by a clinician as part of a full evaluation, and then treated by trained personnel for medical and behavioral interventions. Additional efforts should be made to ensure that parents have access to a knowledgeable pediatrician and are provided with the resources to follow up on the recommendations.

The early screening has made it possible to begin treatments earlier. I would like to see a quantum leap forward with preemptive screening that would identify the risk of a child developing autism well before the symptoms are in evidence. This would then allow immediate steps to be taken to prevent the onset if found to be at high risk. The level of risk can be determined with several bio-markers and appears to offer more than 90 percent accuracy.